Is Clostridioides difficile toxins detection necessary when the glutamate dehydrogenase enzyme is detected?

INTRODUCTION: Clostridioides difficile causes diarrhea and pseudomembranous colitis. Its diagnosis is made with glutamate dehydrogenase (GDH) or toxins A and B detection and is confirmed with nucleic acid amplification tests. OBJECTIVE: To define if GDH determination is redundant to that of toxins. METHODS: Retrospective, observational study in diarrheal stools of patients with suspected Clostridioides difficile infection. Toxins and GDH were determined by immunochromatography. Bayesian simulation was performed with likelihood ratios; a p-value < 0.05 was regarded as significant. RESULTS: 329 GDH and toxin A and B results were analyzed. Clostridioides difficile infection prevalence was 18.2 %. Sensitivity and specificity of the GDH test were 0.90 and 0.89, respectively. Positive likelihood ratio was 8.9, and negative was 0.11. CONCLUSIONS: A negative GDH result considerably reduces the probability of infection but does not rule it out. Clostridioides difficile toxins detection may be necessary in institutions where nucleic acid amplification is not affordable or accessible.

INTRODUCCIÓN: Clostridioides difficile causa diarrea y colitis pseudomembranosa. Su diagnóstico se realiza con la detección de glutamato-deshidrogenasa (GDH) o las toxinas A y B y se confirma con pruebas de amplificación de ácidos nucleicos. OBJETIVO: Definir si la determinación de GDH es redundante a la de las toxinas. MÉTODOS: Estudio observacional retrospectivo de muestras fecales de pacientes con sospecha de infección por Clostridioides difficile. Las toxinas y GDH se determinaron mediante inmunocromatografía. Se realizó una simulación bayesiana con los cocientes de probabilidad; se consideró significativo un valor de p < 0.05. RESULTADOS: Se analizaron 329 resultados de GDH y toxinas A y B. Se encontró una prevalencia de infección de Clostridioides difficile de 18.2 %. La sensibilidad y especificidad de la prueba de GDH fue de 0.90 y 0.89, respectivamente. El cociente de probabilidad positivo fue de 8.9 y el negativo, de 0.11. CONCLUSIONES: Un resultado negativo de GDH disminuye considerablemente la probabilidad de infección, pero no la descarta. La detección de toxinas de Clostridioides difficile puede ser necesaria en instituciones donde la amplificación de ácidos nucleicos no es económica o accesible.

¿La detección de toxinas de Clostridioides difficile es necesaria cuando se detecta la enzima glutamato deshidrogenasa? / Is Clostridioides difficile toxins detection necessary when the glutamate dehydrogenase enzyme is detected?

Resumen Introducción: Clostridioides difficile causa diarrea y colitis pseudomembranosa. Su diagnóstico se realiza con la detección de glutamato-deshidrogenasa (GDH) o las toxinas A y B y se confirma con pruebas de amplificación de ácidos nucleicos. Objetivo: Definir si la determinación de GDH es redundante a la de las toxinas. Métodos: Estudio observacional retrospectivo de muestras fecales de pacientes con sospecha de infección por Clostridioides difficile. Las toxinas y GDH se determinaron mediante inmunocromatografía. Se realizó una simulación bayesiana con los cocientes de probabilidad; se consideró significativo un valor de p < 0.05. Resultados: Se analizaron 329 resultados de GDH y toxinas A y B. Se encontró una prevalencia de infección de Clostridioides difficile de 18.2 %. La sensibilidad y especificidad de la prueba de GDH fue de 0.90 y 0.89, respectivamente. El cociente de probabilidad positivo fue de 8.9 y el negativo, de 0.11. Conclusiones: Un resultado negativo de GDH disminuye considerablemente la probabilidad de infección, pero no la descarta. La detección de toxinas de Clostridioides difficile puede ser necesaria en instituciones donde la amplificación de ácidos nucleicos no es económica o accesible.

Abstract Introduction: Clostridioides difficile causes diarrhea and pseudomembranous colitis. Its diagnosis is made with glutamate dehydrogenase (GDH) or toxins A and B detection and is confirmed with nucleic acid amplification tests. Objective: To define if GDH determination is redundant to that of toxins. Methods: Retrospective, observational study in diarrheal stools of patients with suspected Clostridioides difficile infection. Toxins and GDH were determined by immunochromatography. Bayesian simulation was performed with likelihood ratios; a p-value < 0.05 was regarded as significant. Results: 329 GDH and toxin A and B results were analyzed. Clostridioides difficile infection prevalence was 18.2 %. Sensitivity and specificity of the GDH test were 0.90 and 0.89, respectively. Positive likelihood ratio was 8.9, and negative was 0.11. Conclusions: A negative GDH result considerably reduces the probability of infection but does not rule it out. Clostridioides difficile toxins detection may be necessary in institutions where nucleic acid amplification is not affordable or accessible.

Leptin in embryos from control and diabetic rats during organogenesis: a modulator of nitric oxide production and lipid homeostasis.

BACKGROUND: Leptin is involved in many metabolic and reproductive events and its levels are altered by the diabetic pathology. In this study, leptin concentrations and leptin effects on both nitric oxide (NO) and lipid concentrations were investigated in embryos from control and diabetic rats. METHODS: Diabetes was induced by neonatal streptozotocin administration (90 mg/kg). Embryos from control and diabetic rats were obtained on days 10.5 and 13.5 of gestation, corresponding to early organogenesis and post-placentation periods respectively. Leptin was analysed by enzyme immunoanalysis and immunohistochemistry. Nitrates and nitrites were assessed as an index of NO production. Lipid concentrations were analysed by thin layer chromatography. RESULTS: Leptin concentrations were decreased in embryos obtained from diabetic rats on days 10.5 and 13.5 of gestation when compared to controls. NO concentrations, elevated in diabetic embryopathy, were diminished in the presence of leptin in the embryos obtained from control and diabetic animals both during early organogenesis and after placentation. Leptin additions reduced phospholipid, cholesterol and cholesteryl ester concentrations in embryos obtained from diabetic rats during early organogenesis, although no leptin effects on lipid concentrations were observed in control embryos at this developmental stage. In embryos obtained on day 13.5 of gestation leptin additions reduced cholesteryl ester concentrations in controls, and diminished cholesteryl ester, triglycerides and phospholipids in embryos from diabetic rats. CONCLUSIONS: We demonstrated that leptin plays a role in the regulation of NO concentrations and lipid homeostasis during embryo organogenesis and that the diabetic environment causes a reduction of leptin concentrations in rat embryos.

Leptin modulates nitric oxide production and lipid metabolism in human placenta.

Leptin has significant effects on appetite, energy expenditure, lipid mobilisation and reproduction. During pregnancy, leptin is produced in the placenta, a tissue in which leptin receptors are highly expressed, suggesting autocrine/paracrine functions for this hormone. In the present study, a putative role of leptin as a regulator of nitric oxide (NO) production and lipid metabolism was evaluated in term human placenta. We demonstrated that leptin enhanced NO production in human placental explants (P < 0.01). Although leptin did not modify the placental levels of cholesteryl esters and phospholipids, leptin decreased levels of triglycerides (P < 0.01) and cholesterol (P < 0.001) in term human placenta. The effect of leptin on lipid mass seems to be independent of the modulation of de novo lipid synthesis because leptin did not modify the incorporation of (14)C-acetate into any of the lipids evaluated. We investigated the effects of leptin on placental lipid catabolism and found that in both term human placental explants and primary cultures of trophoblastic cells, leptin increased glycerol release, an index of the hydrolysis of esterified lipids, in a dose-dependent manner. In conclusion, we have shown that leptin affects NO production and lipid catabolism in human placenta, providing supportive evidence for a role of leptin in placental functions that would determine the transfer of nutrients to the developing fetus.

Oxidative stress promotes the increase of matrix metalloproteinases-2 and -9 activities in the feto-placental unit of diabetic rats.

Maternal diabetes increases the risk of congenital malformations, placental dysfunction and diseases in both the neonate and the offspring's later life. Oxidative stress has been involved in the etiology of these abnormalities. Matrix metalloproteases (MMPs), involved in multiple developmental pathways, are increased in the fetus and placenta from diabetic experimental models. As oxidants could be involved in the activation of latent MMPs, we investigated a putative relationship between MMPs activities and oxidative stress in the feto-placental unit of diabetic rats at midgestation. We found that H2O2 enhanced and that superoxide dismutase (SOD) reduced MMPs activities in the maternal side of the placenta and in the fetuses from control and diabetic rats. MMPs were not modified by oxidative status in the fetal side of the placenta. Lipid peroxidation was enhanced in the maternal and fetal sides of the placenta and in the fetus from diabetic rats when compared to controls, and gradually decreased from the maternal placental side to the fetus in diabetic animals. The activities of the antioxidant enzymes SOD and catalase were decreased in the maternal placental side, catalase activity was enhanced in the fetal placental side and both enzymes were increased in the fetuses from diabetic rats when compared to controls. Our data demonstrate changes in the oxidative balance and capability of oxidants to upregulate MMPs activity in the feto-placental unit from diabetic rats, a basis to elucidate links between oxidative stress and alterations in the developmental pathways in which MMPs are involved.

Modulatory effect of leptin on nitric oxide production and lipid metabolism in term placental tissues from control and streptozotocin-induced diabetic rats.

Leptin production by placental tissues contributes to its circulating levels and functions. The diabetic pathology induces alterations in leptin levels. In the present study, leptin levels were evaluated in placental tissue from control and neonatal streptozotocin-induced (n-STZ) diabetic rats during late gestation. The effects of leptin levels on the generation of nitric oxide (NO), prostaglandin (PG) E(2) production and lipid metabolism were examined. Leptin levels were diminished in placentas from n-STZ diabetic rats compared with controls (P < 0.01). These differences were also evident when leptin was evaluated immunohistochemically. Addition of leptin (1 nM) in vitro enhanced NO production in control (66%) and diabetic placentas (134%) by stimulating NO synthase activity (by 38% and 54%, respectively). The addition of leptin increased PGE(2) production in placentas from control (173%) and diabetic rats (83%) and produced a 50% decrease in placental lipid levels (phospholipids, triacylglycerides, cholesterol and cholesteryl ester) without involving a reduction in de novo lipid synthesis. These data indicate that leptin enhances the production of placental NO and PGE(2), vasoactive agents that modify placental blood flow, and that leptin stimulates placental lipid metabolism, probably generating more lipids for transfer to the fetus. In the diabetic rat, placental leptin was reduced, probably as a response to the maternal environment to locally regulate the transfer of nutrients to the developing fetus.

Lipid metabolism in the embryos of diabetic rats during early organogenesis: modulatory effect of prostaglandin E2.

The purpose of this work was to evaluate de novo lipid biosynthesis and the lipid profile, and to study the effect of prostaglandin E2 (PGE2; prostaglandin has previously been found to be involved in diabetes embryopathy) on lipid metabolism in embryos from control and streptozotocin-induced diabetic rats during organogenesis. Increased levels of triacylglycerols were found in embryos of diabetic rats compared with controls, whereas no differences were detected in the levels of cholesterol, cholesterylester, phosphatidylcholine and phosphatidylethanolamine. When the de novo synthesis of lipids in the embryo was studied using [14C]acetate as a tracer, a diminished rate of incorporation of [14C]acetate into the evaluated lipid classes was detected in the diabetic embryo compared with controls. Addition of PGE2 did not modify the incorporation of [14C]acetate into any of the lipid species of control embryos, but enhanced the incorporation of [14C]acetate into triacylglycerol, cholesterylesters, phosphatidylcholine and phosphatidylethanolamine of embryos from diabetic rats. The study's results show alterations in both synthesis and concentrations of lipids in the embryos of diabetic rats. Interestingly, the results demonstrate that the addition of PGE2, a prostaglandin that reverses the embryonic morphological abnormalities induced by diabetes, prevents disturbances in embryo lipid synthesis caused by diabetes.

Nitric oxide induces gelatinase A (matrix metalloproteinase 2) during rat embryo implantation.

OBJECTIVE: To evaluate a reciprocal signaling interaction initiated by embryo-derived nitric oxide (NO) to facilitate implantation by increased production of gelatinase A (matrix metalloproteinase 2, MMP2) in uterine stroma. DESIGN: Experimental animal studies. SETTING: Reproductive-physiology research laboratory. ANIMAL(S): Female syngeneic Wistar rats aged 14 weeks. INTERVENTION(S): Vaginal smears to confirm pregnancy. Oviductal ligature to avoid the descent of blastocysts to the uterine lumen. Plasma exudation assays to locate uterine blastocyst implantation sites. Organ cultures treated with NO donors and nitric oxide synthase (NOS) inhibitors. MAIN OUTCOME MEASURE(S): Expression of MMP2 and NO was assessed by Western blot and zymography of tissue extracts and by immunofluorescence of tissue sections. RESULT(S): An increase in MMP2 activity was found in uterine extracts in early pregnant rats and was concentrated at implantation sites. Immunolocalization experiments showed that inducible NOS was expressed on the surface of the implanting blastocyst adjacent to the uterine epithelium at the sites of increased MMP2 expression. In organ culture experiments, NO donors were found to increase, whereas NOS inhibitors were found to decrease MMP2 activity in uterine tissue sections. CONCLUSION(S): Blastocyst-derived NO contributes to the production of uterine-derived MMP2, an essential component of implantation and initiation of placentation.

Oxidative stress and altered prostanoid production in the placenta of streptozotocin-induced diabetic rats.

The oxidative stress in placental tissues during late pregnancy, as well as the relationship between reactive oxygen species (ROS) and the arachidonic acid (AA) pathway was evaluated in a neonatal streptozotocin (STZ)-induced diabetic rat model. Lipoperoxide levels are increased in diabetic tissues compared with control tissues (P<0.001) and they seem to increase throughout the development of gestation both in control (P<0.05) and STZ-induced diabetic (P<0.001) rats. Superoxide dismutase (SOD) activity is not modified on different days of pregnancy, but enzymatic activity is lower in diabetic tissues than in control tissues (P<0.01). Labour is preceded by an increase in placental 14C-prostaglandin conversion from 14C-AA in control and diabetic animals (P<0.05) and the thromboxane B2 (TXB2)/6-keto-prostaglandin F1alpha (PGF1alpha) ratio is higher in diabetic placental tissues than in controls. The addition of SOD and glutathione to the incubation medium does not modify prostanoid levels in control rats, but does decrease the AA conversion to PGF2alpha, PGE2 and TXB2 (P<0.05) in diabetic placenta. Superoxide radical generation (hypoxanthine/xanthine oxidase or hydrogen peroxide added to the incubation medium) produces a decrease in 6-keto-PGF1alpha (P<0.05) in control and diabetic tissues, whereas PGF2alpha, PGE2 and TXB2 levels, and PGF2alpha and TXB2 production are increased in control and diabetic animals respectively (P<0.05). Diabetic pregnant rats supplemented with a diet containing 400 mg day(-1) of alpha-tocopherol (vitamin E) have diminished placental PGF2alpha and TXB2 production and lipoperoxide levels. The results show a higher TXB2 and a decreased 6-keto-PGF1alpha placental production that may be linked to increased oxidative stress and to a reduced antioxidant capacity in STZ-induced diabetic rats. These imbalances, probably involved in abnormal placental structure and function, may potentially be corrected with dietary supplementation of alpha-tocopherol in diabetic pregnancies.

Levels of endothelin-1 in embryos from control and neonatal streptozotocin-induced diabetic rats, and their relationship with nitric oxide generation.

Endothelin-1 (ET-1), a potent vasoconstrictor peptide and modulator of vasoactive substances such as prostanoids and nitric oxide (NO), plays an important role during embryo and fetal development. In this work, ET-1, nitrate and nitrite, and prostaglandin E2 (PGE2) levels in embryos from control and neonatal streptozotocin-induced (n-stz) diabetic rats were assessed, and the modulatory pathways regulating the generation of these vasoactive agents investigated. Endothelin-1 concentrations were found to be increased in embryos from n-stz diabetic rats when compared with controls. Additions of spermine NONOate, a nitric oxide donor, enhanced ET-1 levels in embryos from both control and n-stz diabetic rats, whereas N(G)-monomethyl-L-arginine, a nitric oxide inhibitor, diminished embryonic ET-1 content. Thus, enhanced ET-1 levels in the embryos from n-stz diabetic rats may be related to the elevated NO levels found in those embryos. Additions of ET-1 or bosentan (an endothelin A and endothelin B receptor antagonist), did not alter PGE2 generation in embryos from either control or n-stz diabetic rats. Endothelin-1 additions diminished nitrate and nitrite levels in embryos from both control and n-stz diabetic rats, whereas bosentan stimulated nitrate and nitrite generation in those embryos. In the present work, it was found that ET-1 levels were enhanced in embryos from n-stz diabetic rats, probably as a result of NO overproduction, an alteration which may be related to embryonic abnormalities and growth delay. Endothelin-1 has been shown to be a negative modulator of embryonic NO levels, a mechanism likely to be important during development. Endothelin-1 may prevent damage induced by NO overproduction in embryos from n-stz diabetic rats.

Streptozotocin-pancreatic damage in the rat: modulatory effect of 15-deoxy delta12,14-prostaglandin j(2) on nitridergic and prostanoid pathway.

15-deoxy-delta (12,14)prostaglandin J(2) (15d-PGJ(2)) has been identified as a natural ligand of the PPARgamma subtype. PPAR activation in nonadipose tissues seems to inhibit iNOS and COX2 expression. Vasoactive compounds like nitric oxide and prostaglandins are increased in pancreatic tissue from streptozotocin-diabetic rats. We hypothesize that 15d-PGJ(2) may regulate the production of these proinflammatory compounds that lead to beta cell destruction in the diabetic pathology. In this work we evaluated Ca(2+)-dependent (cNOS) and Ca(2+)-independent (iNOS) activity, nitrate/nitrite levels, 15-dPGJ(2) and prostaglandin E(2) (PGE(2)) levels in isolated pancreatic islets, and 15d-PGJ(2) levels in plasma from control and streptozotocin-diabetic rats. Our results show that cNOS is predominant in control, while iNOS isoform is increased in the diabetic islets (P < 0.01). 15d-PGJ(2) 10(-5)M inhibits cNOS and iNOS activity both in control and diabetic islets (P < 0.05). Nitrate/nitrite and PGE(2) levels are higher in diabetic than in control islets (P < 0.05 and P < 0.01, respectively). 15d-PGJ(2) 10(-5)M decreases nitrate/nitrite and PGE(2) levels both in control and in diabetic islets. Bisphenol A diglycidyl ether (BADGE), a recently described PPARgamma antagonist, seems to act as a PPARgamma agonist, diminishing nitrate/nitrite and PGE2 levels in control and diabetic islets. 15d-PGJ(2) production is lower in islets from diabetic animals compared to control (P < 0.05). Our observations suggest that 15d-PGJ(2) is able to diminish the production of vasoactive proinflammatory agents in pancreatic islets. The diminished 15d-PGJ(2) levels in the diabetic islets are probably related to the diminished capacity to limit the inflammatory response due to experimental diabetes in the rat.

Metalloproteinase 2 activity and modulation in uterus from neonatal streptozotocin-induced diabetic rats during embryo implantation.

Matrix metalloproteinases (MMPs) are responsible for the remodelling of the uterine extracellular matrix during embryo implantation. Nitric oxide (NO) production is increased at the time when implantation begins. Abnormal tissue levels of MMPs are present in diabetes; elevated NO levels in tissues and an increased oxidative stress are also found. The present work evaluates the uterine MMP2 activity and levels during embryo implantation, as well as the influence of nitridergic compounds and reactive oxygen species (ROS) on the MMP2 enzymatic activity in a model of neonatal streptozotocin-induced diabetic rat. Metalloproteinase 2 activity and levels are increased in diabetic tissues compared with controls (P < 0.05 and P < 0.002 respectively). The uterine enzymatic activity in diabetic animals decreases in the presence of the NOS inhibitor NG-nitro-L-arginine methyl ester (P < 0.01) and is enhanced (P < 0.005) when a generating ROS system (xanthine/xanthine oxidase) is added to the incubating medium. It was also found that uterine superoxide dismutase activity is higher in diabetic rats than in control rats on the day of implantation (P < 0.001), suggesting a compensatory antioxidant ability. In conclusion, the results show that the uterine MMP2 activity, which is higher in diabetic animals than in control animals, is modulated positively by NO and ROS during embryo implantation in a model of streptozotocin-induced diabetic rats.

Investigación de la deficiencia de hierro en pacientes con insuficiencia renal crónica en hemodiálisis / Investigation of iron deficiency in patients with chronic kidney failure in hemodialysis

Se estudiaron 19 pacientes con IRC, en hemodiálisis entre 1 y 108 meses. Siete eran mujeres (22-65 años) y 12 varones (22-66 años). La causa de la IRC fue GNC 4, PNC 3, nefroangioesclerosis 3, GNMP 2, uropatía obstructiva 2, indeterminada 2, poliquistosis 1, nefronoptisis 1 y GNPD 1. Nueve pacientes habían recibido transfusiones en el año previo al estudio, pero ninguno había sido tratado con hierro ni con eritropoyetina. La hemocitometría se realizó con un analizador electrónico, también se midió la ferremia, la transferinemia, la ferritina sérica, y el hierro medular en una proporción de los casos. Se observó una correlación significativa entre la ferritina sérica y el hierro medular. La asociación VCM menor de 80 fl y HCM menor de 27 pg tuvo valor predictivo para deficiencia de hierro (ferritina sérica menor de 30 ng/ml y/o hierro medular menor de dos cruces), con 60% de sensibilidad y 100% de especificidad. La ferremia y la saturación de la transferrina no fueron útiles para el diagnóstico de deficiencia de hierro en la IRCHD. Cinco de los 19 pacientes estudiados tenían deficiencia de hierro (26%), y 2 de ellos respondieron favorablemente a la administración parenteral del mismo. El empleo racional de la eritropoyetina recombinante, para el tratamiento de la anemia en la IRCHD, hace necesario investigar la posible deficiencia de hierro así como de otros factores hemopoyéticos en estos pacientes

Investigación de la deficiencia de hierro en pacientes con insuficiencia renal crónica en hemodiálisis / Investigation of iron deficiency in patients with chronic kidney failure in hemodialysis

Se estudiaron 19 pacientes con IRC, en hemodiálisis entre 1 y 108 meses. Siete eran mujeres (22-65 años) y 12 varones (22-66 años). La causa de la IRC fue GNC 4, PNC 3, nefroangioesclerosis 3, GNMP 2, uropatía obstructiva 2, indeterminada 2, poliquistosis 1, nefronoptisis 1 y GNPD 1. Nueve pacientes habían recibido transfusiones en el año previo al estudio, pero ninguno había sido tratado con hierro ni con eritropoyetina. La hemocitometría se realizó con un analizador electrónico, también se midió la ferremia, la transferinemia, la ferritina sérica, y el hierro medular en una proporción de los casos. Se observó una correlación significativa entre la ferritina sérica y el hierro medular. La asociación VCM menor de 80 fl y HCM menor de 27 pg tuvo valor predictivo para deficiencia de hierro (ferritina sérica menor de 30 ng/ml y/o hierro medular menor de dos cruces), con 60% de sensibilidad y 100% de especificidad. La ferremia y la saturación de la transferrina no fueron útiles para el diagnóstico de deficiencia de hierro en la IRCHD. Cinco de los 19 pacientes estudiados tenían deficiencia de hierro (26%), y 2 de ellos respondieron favorablemente a la administración parenteral del mismo. El empleo racional de la eritropoyetina recombinante, para el tratamiento de la anemia en la IRCHD, hace necesario investigar la posible deficiencia de hierro así como de otros factores hemopoyéticos en estos pacientes

Investigación de la deficiencia de hierro en pacientes con insuficiencia renal crónica en hemodiálisis / Investigation of iron deficiency in patients with chronic kidney failure in hemodialysis

Se estudiaron 19 pacientes con IRC, en hemodiálisis entre 1 y 108 meses. Siete eran mujeres (22-65 años) y 12 varones (22-66 años). La causa de la IRC fue GNC 4, PNC 3, nefroangioesclerosis 3, GNMP 2, uropatía obstructiva 2, indeterminada 2, poliquistosis 1, nefronoptisis 1 y GNPD 1. Nueve pacientes habían recibido transfusiones en el año previo al estudio, pero ninguno había sido tratado con hierro ni con eritropoyetina. La hemocitometría se realizó con un analizador electrónico, también se midió la ferremia, la transferinemia, la ferritina sérica, y el hierro medular en una proporción de los casos. Se observó una correlación significativa entre la ferritina sérica y el hierro medular. La asociación VCM menor de 80 fl y HCM menor de 27 pg tuvo valor predictivo para deficiencia de hierro (ferritina sérica menor de 30 ng/ml y/o hierro medular menor de dos cruces), con 60% de sensibilidad y 100% de especificidad. La ferremia y la saturación de la transferrina no fueron útiles para el diagnóstico de deficiencia de hierro en la IRCHD. Cinco de los 19 pacientes estudiados tenían deficiencia de hierro (26%), y 2 de ellos respondieron favorablemente a la administración parenteral del mismo. El empleo racional de la eritropoyetina recombinante, para el tratamiento de la anemia en la IRCHD, hace necesario investigar la posible deficiencia de hierro así como de otros factores hemopoyéticos en estos pacientes